Why SF should open a supervised drug-injection facility

If there’s any good news, it’s this: Effective addiction treatments
exist for opioid use disorders, and many of injection’s most serious
harms are preventable.

If there’s any good news, it’s this: Effective addiction...

Just under a decade ago, Philippe Bourgeois published “Righteous Dopefiend,” his chronicle of homeless, heroin-injecting San Franciscans making their lives on the city’s streets. The book’s publication turned out to be chillingly well-timed: Since 2010, opioid-related deaths have skyrocketed, tearing apart communities and leading, for the first time in decades, to declining life expectancy across swaths of the American population.

Those featured in “Righteous Dopefiend” often encountered heroin in the hard-living years of the 1970s and 1980s. By contrast, the current epidemic largely started with prescription painkillers. But, efforts to crack down on pills are leading a new generation to turn to heroin, and with it, the needle.

Drug injection, an efficient way to get high, is also a dangerous one.

Dosing can be hard to control, increasing overdose risk. Equipment sharing can lead to HIV, hepatitis C, and other serious chronic illnesses. Bacterial infections of the skin, heart or central nervous system can send people to the hospital for days or weeks. When I worked as a medical intern at Zuckerberg San Francisco General Hospital, these sorts of infections were among the most common reasons for admission to our service. As more people turn to injection, all these complications will become more common. The costs, both human and economic, will be high.

If there’s any good news, it’s this: Effective addiction treatments exist for opioid use disorders, and many of injection’s most serious harms are preventable. Treatments include methadone and buprenorphine, the mainstays of opioid replacement therapy. Naltrexone, a medication that blocks opioid receptors, is a promising option as well.

Psychiatric medication, therapy, and group programs can all play important roles. Then there are critically important harm-reduction programs, which often take the form of needle and syringe exchange, where people who inject can get clean supplies. More recently, the distribution of naloxone, an effective overdose antidote, has gained widespread popularity.

Now, San Francisco is debating an approach that, though not new, is still viewed by many as radical: the supervised injection facility, a place where people who inject drugs can drop in — with their own supply — and use. An on-site needle exchange allows easy access to clean equipment. Clients then go to a clean location — be it a booth or a lounge chair, where they can inject. All the while, staff trained to respond quickly to overdose or other emergencies stand at the ready.

These facilities offer people who inject drugs safety, support and dignity, worthy goals in and of themselves. Furthermore, they offer a one-stop point of connection to detox, treatment, counseling services and other resources, gaining the trust of people who may have more than a little well-earned skepticism of government and public health authorities.

Worldwide, there are around 100 supervised injection facilities, most of them in Europe. For more than a decade, North America’s only facility was Insite, which opened in 2003 in Vancouver, British Columbia (more recently, the city added a second facility).

Insite’s statistics speak for themselves. In 2016, the facility served more than 8,000 clients, providing approximately 1,700 overdose interventions, 4,000 clinical interventions, 517 referrals to the facility’s attached detox program, and more than 5,000 referrals to other social and health services. By conservative estimates, Insite offered an economic benefit of $6 million per year, a return of $5 for every $1 spent, with no substantive evidence that it encouraged continuing drug use for those intent on quitting. Perhaps most impressive of all, in its 15 years of operation, Insite has not seen a single overdose death.

Despite opposition among conservatives, Insite’s remarkable success led the Canadian government to approve additional sites. The United States still has no sanctioned facilities, which would make San Francisco’s the first (if Seattle doesn’t beat us to it). Even if we were to move forward here, the potential for both clients and operators to face legal jeopardy is substantial. In Sacramento, a recent effort to create a framework for supervised injection facilities failed, leaving a lack of clarity as to how, if at all, California authorities might respond. Federal law may be an even tougher barrier. Recently, the U.S. Attorney in Vermont — relying on unsubstantiated claims about the supposed dangers of supervised injection sites — threatened legal action against a proposed facility there. Needless to say, any effort to open a site here would require careful assessment and negotiation of the legal risks to city officials, site operators, and clients themselves.

And yet, how can we wait? We, as a country, are faced with a true public health emergency, and it’s time to act like it. Thus far, the worst of the opioid epidemic has largely spared California, relatively speaking, but with an estimated 22,500 people who inject drugs in San Francisco, the need for a supervised injection facility remains great.

A recent San Francisco study estimated that a 13-booth site would, through averted infections and increased opioid treatment, generate a net return of $3.5 million annually. Even greater than the economic savings is the opportunity to clearly take the position that we, as a city, value the safety, health and lives or all our citizens — and to demonstrate that this model can work in the United States. California can once again set an example for the nation; the stakes are too high to wait.

Jacob Izenberg is a resident physician in psychiatry at UCSF and a drug-use researcher, with his most current research focused on gentrification and health in California.